Urge Incontinence

How urge incontinence happens

Normally the bladder fills quietly, and the brain holds back the urge until it is convenient to urinate. In urge incontinence, the bladder muscle (detrusor) contracts on its own during filling (detrusor overactivity), creating a sudden urgent need to go. If the contraction is stronger than the urethral sphincter can resist, urine leaks. People often leak a moderate to large amount, sometimes emptying the whole bladder.

Urge vs stress incontinence

Many people have both, called mixed incontinence. See stress incontinence.

Causes and risk factors

• overactive bladder without an identifiable cause (idiopathic), the most common
• bladder irritants: caffeine, alcohol, carbonated and artificially sweetened drinks, citrus, spicy foods
• urinary tract infections
• menopause: low estrogen thins the bladder and urethral lining
• enlarged prostate in men, causing bladder overactivity
• nerve conditions: stroke, MS, Parkinson's disease, dementia, spinal cord disease. See neurogenic bladder
• bladder stones and, rarely, bladder cancer
• constipation
• obesity, diabetes and smoking
• medicines: diuretics and some sedatives
• reduced mobility, making it harder to reach the toilet

Symptoms

• a sudden, strong urge to urinate followed by leaking
• going frequently, often more than 8 times a day
• waking at night to urinate (nocturia) or wetting the bed
• leaking triggered by running water, cold, or "key in the door"
• planning activities around toilet access

Diagnosis

• history: when leaks happen, how much, triggers, fluids, medicines, childbirth, surgery and neurological symptoms
• bladder diary for 3 days, recording fluids, voids, volumes and leaks
• urinalysis to check for infection, blood or sugar
• post-void residual bladder scan to make sure the bladder empties
• examination: abdominal, pelvic exam in women (for prolapse and vaginal atrophy) and prostate exam in men
• urodynamic studies if the diagnosis is unclear, before surgery, or when first treatments fail
• cystoscopy for blood in the urine or persistent unexplained symptoms

Treatment

First-line: behavioral changes

• bladder training: urinate on a schedule, gradually stretching the interval by 15 to 30 minutes every week or two
• urge suppression: when an urge strikes, stop, stand still, do several quick pelvic floor squeezes, breathe and wait until it fades, then walk calmly to the toilet
• pelvic floor muscle training, ideally with a specialist physical therapist
• reduce bladder irritants, especially caffeine and alcohol
• manage fluids: drink enough to keep urine pale, but avoid large amounts at once or in the evening
• treat constipation, lose weight and stop smoking

Medicines

• beta-3 agonists (mirabegron, vibegron): relax the bladder, with fewer side effects such as dry mouth
• antimuscarinics (oxybutynin, solifenacin, tolterodine, trospium): effective but can cause dry mouth, constipation and, in older adults, confusion. Guidelines advise caution about cognitive effects
• vaginal estrogen for postmenopausal women
• alpha-blockers in men with prostate enlargement

Procedures

• Botox (onabotulinumtoxinA) injections into the bladder wall, lasting 6 to 12 months. A small number of people need to self-catheterize temporarily afterward
• percutaneous tibial nerve stimulation: weekly 30-minute treatments with a fine needle at the ankle
• sacral neuromodulation: an implanted device that regulates bladder nerve signals
• bladder augmentation surgery, rarely, for severe cases

Practical aids

Absorbent pads and pants, bedside commodes and planning toilet access can maintain confidence while treatment takes effect.

Frequently asked questions

What is urge incontinence?

Urge incontinence is leaking urine that happens with a sudden, strong need to urinate that you cannot hold back long enough to reach a toilet. It is usually caused by an overactive bladder muscle that contracts without warning.

What causes urge incontinence?

The most common cause is overactive bladder. Other causes include urinary tract infections, bladder irritants like caffeine and alcohol, menopause, an enlarged prostate, constipation, and nerve conditions such as stroke, MS and Parkinson's disease.

What is the difference between urge and stress incontinence?

Urge incontinence is leaking with a sudden strong urge, from bladder overactivity. Stress incontinence is leaking with coughing, sneezing, lifting or exercise, from a weak pelvic floor or urethral support. Many people have both, called mixed incontinence.

Can urge incontinence be cured?

Many people are cured or greatly improved. Bladder training, pelvic floor therapy and cutting bladder irritants help a large share. Medicines, Botox injections and nerve stimulation help most of those who need more, though treatment may need to continue long-term.

What drinks make urge incontinence worse?

Caffeine (coffee, tea, energy drinks), alcohol, carbonated drinks, artificially sweetened drinks and citrus juices can irritate the bladder and worsen urgency. Water is best. Avoid large amounts of any fluid in the evening if you wake at night to urinate.